Updated: 11/6/2018

Neisseria gonorrhoeae

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Snapshot

discharge of gonorrhea
  • A 19-year-old male college student presents to the clinic complaining of a burning sensation with urination as well as purulent urethral discharge. He admits to rarely using condoms during sexual intercourse, and does not recall the last time he was tested for sexually-transmitted infections. Urinalysis is positive for leukocyte esterase and a Gram stain shows intracellular diplococci within polymorphonuclear neutrophils.
Introduction
  • Classification
    • Neisseria
      • Gram-negative diplococci
      • often intracellular within neutrophils
  • Epidemiology
    • incidence
      • the second most common bacterial sexually-transmitted infection (after Chlamydia)
    • location
      • genital tract
    • risk factors
      • unprotected sexual intercourse 
  • Pathogenesis
    • mechanism
      • molecular biology
        • pili facilitate attachment to mucosal surfaces
        • antigenic variation  
        • IgA protease allows invasion of mucosal surfaces
        • contains lipooligosaccharides (LOS) with strong endotoxin activity
      • invasion of mucosal surfaces results in inflammation
    • transmission
      • sexual
      • perinatal
  • Associated conditions
    • septic arthritis 
    • neonatal conjunctivitis (2-5 days after birth) 
      • prophylaxis with erythromycin eye drops
    • pelvic inflammatory disease (PID)
    • Fitz-Hugh-Curtis syndrome
Presentation
  • Symptoms
    • dysuria
    • purulent discharge
    • fever
    • prostatitis (men)
    • endocervicitis (women)
    • urethritis
Studies
  • Labs
    • Cervical and urethral culture
      • Thayer-Martin agar
        • selects for growth of Neisseria
        • contains vancomycin, trimethoprim, colistin, and nystatin to inhibit growth of Gram-positive organisms, Gram-negative organisms except for Neisseria, and fungi
    • Nucleic acid amplification testing (NAAT)
  • Histology
    • Gram stain of a cervical swab
      • Gram-negative kidney-shaped diplococci 
Differential
  • Chlamydia
    • distinguishing factor
      • visualization of intracytoplasmic inclusions (reticulate bodies) on histology
  • Urinary tract infection
    • distinguishing factor
      • lack of growth on Thayer-Martin agar
  • Genital herpes simplex
    • distinguishing factor
      • painful vesicles and ulcers
Treatment
  • Medical
    • IM ceftriaxone
      • add azithromycin or doxycycline for possible concomitant chlamydial infection
Complications
  • Pelvic inflammatory disease (PID)
    • may include salpingitis, endometritis, hydrosalpinx, tubo-ovarian abscess
    • risk factor for ectopic pregnancy, infertility, chronic pelvic pain, and adhesions
  • Fitz-Hugh-Curtis Syndrome
    • perihepatitis
      • infection and inflammation of liver capsule
      • adhesions of peritoneum to liver
Comparison with N. meningitidis
 
Characteristics N. gonorrhoeae N. meningitidis
Appearance
  • Kidney-bean shaped diplococci
Oxidase test
  • Positive
Polysaccharide capsule
  • No
  • Yes
Fermentation
  • Glucose ("Gonococci")
  • Maltose and Glucose ("MeninGococci")
Transmission
  • Sex
  • Respiratory
Vaccine
  • No (due to rapid antigenic variation)
  • Yes
β-lactamase production
  • Common
  • Rare
IgA protease production
  • Yes
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MC.74) A 26-year-old male presents to his primary care physician with complaints of burning with urination, penile discharge, and intermittent fevers. A urethral smear shows gram negative diplococci within white blood cells. The organism grows well when cultured on Thayer-Martin agar. The patient is prescribed a course of ceftriaxone and the infection resolves without further complication. One year later, the patient returns with the same infection. Which of the following best explains this lack of lasting immunity? Review Topic

QID: 106692
1

Exotoxin release

0%

(0/8)

2

Antigenic variation

88%

(7/8)

3

Polysaccharide capsule

0%

(0/8)

4

Bruton's agammaglobulinemia

0%

(0/8)

5

Lack of necessary vaccination

0%

(0/8)

M1

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